"Soup cans, brooms, and Zoom:" Rapid conversion of a cancer survivorship program to telehealth during <scp>COVID</scp>‐19

Abstract

In the context of COVID-19, challenges faced by cancer survivors have intensified. Posttreatment survivors already feel untethered from their cancer care community.1, 2 The pandemic has suddenly and drastically reduced opportunities for social connection and support due to social distancing and limits on access to hospitals and clinics. Survivors face a heightened sense of vulnerability to COVID-19, a higher perceived risk of disease complication, intensified fear of recurrence, anxiety around disruption of medical services, and reduced safe access to basic nutrition and physical activity.3-5 Increased household demands, dependent care, and rising financial insecurity amplify the stress. Inequities across social groups add further suffering.5 Survivors need support more than ever to maintain health and well-being, experience connection, and face public health risks outside their control. The University of California, San Francisco (UCSF) Psycho-Oncology service sought to meet these needs by rapidly transferring the Survivorship Wellness Group Program (SWGP),6 an evidence-based health behavior change program, to telehealth and adding COVID-19 relevant content. Traditionally offered in-person, SWGP includes 8 weekly sessions, led by an interdisciplinary team, on nutrition, exercise, stress, sleep and fatigue, sexuality and body image, emotional wellness and fear of recurrence, spirituality, and health promotion, with monthly sessions on specialized survivorship topics. SWGP has received consistently high patient satisfaction ratings but encountered enrollment challenges related to access. UCSF serves a catchment area across rural and urban Northern and Central California. Patients living at a great distance, and those with transportation issues, dependent care, and scheduling conflicts, were seldom able to attend. Prior to telehealth conversion, the in-person program was reimbursable under insurance. Telehealth adaptation was facilitated when reimbursement was extended to cover group behavioral telehealth interventions in response to the needs of patients during COVID-19. We transitioned SWGP to Zoom7 in 14 days from the date of the local shelter-in-place ordinance 16 March 2020. While advances in telehealth offer potential for psychosocial care, challenges include variation in patients' comfort with and access to technology.8-10 Operational efforts therefore focused on ensuring patient safety, confidentiality, quality of experience, comfort with technology, and engagement (Table 1). We modified program content to accommodate COVID-19 needs for survivors. Group discussion included heightened risk and fear of falling ill, health-related vigilance, and risk associated with potential delays in surveillance or other survivorship care. Facilitators tailored approaches to adapting available resources to maintain health and well-being and a sense of community and connectedness. The SWGP curriculum was revised by necessity. The physical activity curriculum embraced the use of unconventional materials such as brooms, soup cans, and other household items for in-home exercises. Nutritional content focused on modifications, including identification of foods that may be well preserved by freezing, nutritional diversity despite an unpredictable food supply, and strategies for those with food insecurity. Curriculum on sleep addressed increased anxiety and stay-at-home orders. Stress management included managing the impact of media to "be well-informed, not over-informed or misinformed." The importance of social connection while physical distancing was emphasized. Finally, spiritual wellness prioritized reflection and intention-setting for personal values (community, kindness, and philanthropy) in this time of unique hardship. After conversion to telehealth, participation surged as the program became instantly accessible to more survivors. Average attendance to the mandatory monthly orientation tripled when it moved online, with the highest recorded orientation attendance in May 2020 over the 2.5-year history of the program. Mean SWGP session attendance rose from 5.5 to 9.8 patients. Survivors shared that telehealth removed previously cited barriers of distance and dependent care scheduling conflicts. Others reported greater availability during stay-at-home orders or expressed preferring in-person services. The increase in attendance also coincided with patient reports regarding a greater need for behavioral health and social support services in the context of COVID-19. High satisfaction ratings were sustained across the transition to telehealth. In a rapid response to the needs of cancer survivors during COVID-19, the SWGP transitioned to telehealth and adapted content, increased accessibility, and expanded the reach of the program while maintaining the quality of the intervention and its foundation in evidenced-based health behavior change. Challenges remain, particularly unequal access to the technology and physical privacy required for optimal participation and safety, and accommodating patients who prefer in-person support. Cancer survivors need patient-centered flexible, accessible programs that meet emotional, physical, and spiritual needs, and more survivors may be reached by telehealth-based offerings, particularly if access to the internet is expanded.1, 2, 9, 10 It is important to note that sustainability will rely on continued institutional support and reimbursement for telehealth-based behavioral health group services. Programming that responds to the unique COVID-19 related needs of cancer survivors especially those disproportionately impacted by social disparities is an ongoing need. As demonstrated by the rapid adaptation of the Survivorship Wellness program, cancer centers are uniquely positioned to offer interdisciplinary services to survivors at this critical transition in their care, made more critical in the context of COVID-19. Funding was provided by the UCSF Mount Zion Health Fund. This activity was approved by the UCSF Institutional Review Board. Dr Shumay reports personal fees from Bluenote Therapeutics and personal fees from RobinCare outside the submitted work. The authors report no other conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.